Application Effect of a Porcine Trachea Model in Cricothyrotomy Teaching and Training

Application Effect of a Porcine Trachea Model in Cricothyrotomy Teaching and Training | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Application Effect of a Porcine Trachea Model in Cricothyrotomy Teaching and Training Yuhao Zhang, Yangkun Li, Jiacheng Fu, Wuhua Ma, Yong Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7752213/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : To investigate the application of a porcine trachea model for teaching and training in cricothyrotomy and to provide a novel method for clinical teaching and training. Methods : Trainees undergoing airway management training at The First Affiliated Hospital of Guangzhou University of Chinese Medicine from January to July 2025 were enrolled. A training model combining theoretical instruction, skills training, and assessment was adopted, utilizing a porcine trachea model for cricothyrotomy training. Theoretical knowledge scores and self-evaluations were recorded before training, after theoretical instruction, and after skills training. Skill assessment scores and operation times were recorded after both the theoretical and skills training sessions. Results : A total of 62 trainees completed the theoretical, self-evaluation, and skills assessments. Compared to pre-training levels, theoretical knowledge scores were significantly higher after both theoretical instruction (P < 0.001) and skills training (P < 0.001). Furthermore, theoretical scores after skills training were significantly higher than those after theoretical instruction alone (P<0.01). Compared to the post-theoretical instruction assessment, skills assessment scores were significantly higher (P<0.001) and operation times were significantly shorter (P <0.001) after skills training. Trainee confidence was significantly improved after both theoretical instruction (P<0.001) and skills training (P<0.001) compared to baseline. Confidence was also significantly higher after skills training compared to after theoretical instruction alone (P<0.001). The proficiency score for performing scalpel cricothyrotomy on the porcine trachea model was significantly higher after skills training than after theoretical instruction (P < 0.001). Conclusion : The training model that combines theoretical instruction, skills training, and assessment is an effective and feasible method for postgraduate medical personnel to learn cricothyrotomy skills. This model enables trainees to enhance their theoretical knowledge, practical skills, and confidence within a short period. Health sciences/Health care Health sciences/Medical research Cricothyrotomy Porcine trachea Training Postgraduate medical education Figures Figure 1 Introduction Airway management is a fundamental clinical skill that all medical personnel must master. Cricothyrotomy, a critical procedure involving either puncture or incision of the cricothyroid membrane, serves as the final line of defense in securing a patient's airway. It is an essential life-saving intervention used to resolve upper airway obstruction caused by factors such as tracheal blockage or bronchospasm, thereby maintaining airway patency and improving patient oxygenation. It is a vital and effective emergency procedure for managing conditions like asphyxia and laryngeal edema. In emergent scenarios involving upper airway obstruction or severe maxillofacial trauma, where tracheal intubation is either impossible or has failed, immediate cricothyrotomy should be performed. While cricothyroid puncture can be performed, its efficacy in providing adequate ventilation is not guaranteed due to the limited diameter of the needle. In contrast, cricothyrotomy is a rapid and relatively simple procedure that can provide effective oxygenation and ventilation, making it the indispensable rescue skill in a "Can't Intubate, Can't Oxygenate" (CICO) crisis. Drawing upon existing literature and prior training experience, this study implemented a training program for cricothyrotomy using a porcine trachea model. The program integrated theoretical instruction, hands-on skills training, and comprehensive assessment. The objective is to evaluate the effectiveness of this approach and to propose a feasible, time-efficient, and highly effective training modality for medical personnel to master this critical skill, and ultimately ensure the safety of patients' lives. Materials and Methods Source of Biological Materials The porcine tracheae used in this training model were procured as by-products from a local abattoir (market) and were purchased commercially. No animals were sacrificed specifically for the purpose of this study. The use of such tissue is therefore exempt from approval by an institutional animal ethics committee, as it utilizes tissue that would otherwise be discarded. Study Participants A total of 65 trainees participating in an airway management training program at The First Affiliated Hospital of Guangzhou University of Chinese Medicine between January and July 2025 were enrolled in this study. The cohort comprised 42 resident physicians and 23 attending physicians. Inclusion criteria were as follows: (1) No prior formal training in cricothyrotomy. (2) Voluntary participation in the training program. Exclusion criteria were as follows: (1) Inability to attend the entire training program, including all skills assessments. (2) Failure to complete all required questionnaires, including the theoretical knowledge tests and self-evaluations. Study Design and Procedure The training program consisted of two parts: theoretical instruction and skills training. All participants underwent a theoretical knowledge assessment and a self-evaluation questionnaire at three time points: 5 minutes before the training, 5 minutes after the theoretical instruction, and 5 minutes after the skills training. Skills assessments were conducted 10 minutes after the completion of both the theoretical instruction and the skills training sessions, respectively. Theoretical Instruction The theoretical instruction covered relevant neck anatomy, including the cricothyroid membrane, thyroid cartilage, and cricoid cartilage, as well as knowledge related to the scalpel cricothyrotomy technique [1]. The anatomy lecture focused specifically on adjacent bony structures, muscle tissues, and the surface landmarking of the cricothyroid membrane. The duration of the theoretical instruction was 30 minutes. Theoretical Knowledge Assessment and Self-Evaluation Theoretical knowledge was assessed using an electronic questionnaire. Self-evaluation included scores for operational proficiency and confidence. Proficiency was rated on a Numeric Rating Scale (NRS) [2], where participants selected a number from 0 (not proficient) to 10 (very proficient), with 1-3 representing basic proficiency and 4-6 representing moderate proficiency. Confidence was rated on a 5-point Likert scale [3], where 1 = very unconfident, 3 = uncertain, and 5 = very confident. Skills Training and Assessment During the skills training session, an instructor demonstrated the cricothyrotomy procedure on a porcine trachea model (a complete porcine larynx including the epiglottis, glottis, thyroid cartilage, cricothyroid membrane, cricoid cartilage, and trachea). The instructor also addressed questions that arose during the theoretical session. The skills training session lasted for 45 minutes. For hands-on practice, participants were divided into small groups, with no more than five trainees per group. Details of the practice are provided in Fig1. Cricothyrotomy skills were assessed after the theoretical instruction and again after the skills training. During the assessment, an instructor evaluated and timed each trainee's performance using a standardized scoring checklist. Outcome Measures The following data were collected: (1) General demographic information of the trainees, including academic qualifications and years of work experience; (2) Theoretical knowledge scores of trainees before training, after theoretical instruction, and after skills training; (3) Success rate and time taken for performing cricothyrotomy on the porcine model; (4) Trainee confidence scores before training, after theoretical instruction, and after skills training. Statistical Analysis Statistical analysis was performed using SPSS version 25.0. Normally distributed continuous data were expressed as mean ± standard deviation (SD) and compared using the t-test. Repeated measures data were analyzed using one-way analysis of variance (ANOVA). Non-normally distributed continuous data were expressed as median (interquartile range, Q1-Q3) and compared using the Mann-Whitney U test. Categorical data were presented as counts (percentages) and compared using the Chi-square (χ²) test. A P-value < 0.05 was considered statistically significant. Ethics approval and consent to participate This project is derived from the Traditional Chinese Medicine (TCM) Continuing Education Program (GZZYJJTJ1917029), which was reviewed, discussed and approved for implementation by the Expert Committee of the State Administration of Traditional Chinese Medicine (SATCM). The Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine waived ethical review for this project, as it had already passed SATCM’s expert review. Prior to the project, participants received training and were informed of project details. The study was conducted in line with the Declaration of Helsinki, with informed consent obtained from all participants. Additionally, the data collected was objective and authentic, with no privacy concerns involved. Results Participant Demographics A total of 62 trainees successfully completed all theoretical, self-evaluation, and skills assessments. The cohort consisted of 38 females (61.29%) and 24 males (38.71%). Regarding academic qualifications, 11 (17.74%) held a bachelor's degree, 44 (70.97%) a master's degree, and 7 (11.29%) a doctoral degree. In terms of professional experience, 25 trainees (40.32%) had less than 5 years of experience, 32 (51.61%) had 5 to 10 years, and 5 (8.06%) had over 10 years. Theoretical Knowledge Assessment The mean theoretical knowledge scores were 71.85 ± 11.50 pre-training, 92.58 ± 5.78 after theoretical instruction, and 95.00 ± 3.37 after skills training. Compared to the pre-training scores, a significant improvement was observed after both theoretical instruction (P < 0.001) and skills training (P < 0.001). Furthermore, scores after skills training were significantly higher than those after theoretical instruction alone (P < 0.01). Skills Assessment The success rate for performing scalpel cricothyrotomy on the porcine model increased from 75.8% (47/62) after theoretical instruction to 95.2% (59/62) after skills training. The mean skills assessment score significantly increased from 70.74 ± 1.74 after theoretical instruction to 95.08 ± 0.49 after skills training (P < 0.001). Concurrently, the mean time required to complete the procedure was significantly reduced from 46.72 ± 1.97 seconds to 22.20 ± 0.67 seconds (P < 0.001). Self-Evaluation Mean self-reported confidence scores were 1.58 ± 1.02 pre-training, 3.23 ± 1.06 after theoretical instruction, and 4.29 ± 0.93 after skills training. Compared to baseline, trainee confidence increased significantly after both theoretical instruction (P < 0.001) and skills training (P < 0.001). Confidence levels were also significantly higher after skills training compared to after theoretical instruction alone (P < 0.001). The self-rated proficiency score for performing scalpel cricothyrotomy on the porcine model was significantly higher after skills training (8.28 ± 1.35) compared to after theoretical instruction (5.74 ± 0.88) (P < 0.001). Discussion Cricothyroidotomy (puncture or incision) and tracheostomy are essential components of front-of-neck airway (FONA) rescue[1]. Although infrequently performed in practice, these procedures play an irreplaceable role in rescuing patients with upper airway obstruction or an unanticipated difficult airway. Failure to establish a timely and effective surgical airway can lead to irreversible brain injury or death[2]. Tracheostomy is a well-known method for establishing an airway[3], and historically, its mastery was required for all surgeons. However, with technological advancements and increasing sub-specialization, this requirement has diminished. Inexperienced junior surgeons may find it more time-consuming compared to cricothyrotomy[3,4]. Consequently, an increasing number of airway management guidelines recommend that anesthesiologists opt for cricothyrotomy in "Can't Intubate, Can't Oxygenate" (CICO) scenarios [5,6]. The incidence of CICO emergencies has decreased with the widespread adoption of advanced airway devices such as video laryngoscopes, laryngeal masks, and flexible endoscopes[7,8]. As a result, many medical professionals lack experience with cricothyrotomy[9]. Emergency cricothyroid puncture, due to the small cannula diameter and difficulty in securing the device, often fails to provide sustained, effective ventilation. In contrast, cricothyrotomy is a rapid and relatively simple procedure that provides effective oxygenation and ventilation, positioning it as the definitive solution in the emergency airway algorithm[10]. However, studies have revealed a lack of experience in performing surgical airways among anesthesiologists and a low success rate for the procedure[5,11]. Therefore, enhancing the training of medical personnel in cricothyrotomy is of paramount importance. While clinical practice is an effective way to improve skills, the low incidence of cricothyrotomy and the need for it to be performed by the most experienced physician preclude its use as a training opportunity[12–14]. In this study, based on existing literature and prior experience, we utilized a porcine trachea model that includes the thyroid cartilage, cricoid cartilage, and cricothyroid membrane. This model provides realistic anatomical landmarks, closely simulating the actual procedure and facilitating rapid skill acquisition. We adopted a multimodal teaching approach that integrated "theoretical instruction, skill demonstration, small-group practice, and assessment." This structure allowed trainees to build upon a theoretical foundation with hands-on training. The small-group practice sessions were designed to enhance trainee engagement and learning efficiency, enabling instructors to monitor individual progress and provide immediate corrective feedback. The effectiveness of this training model was evaluated across three dimensions: theoretical knowledge, technical skill, and self-assessment. Our results demonstrate that this combined approach led to a significant improvement in theoretical knowledge, proving superior to theoretical instruction alone. Regarding self-evaluation, trainees reported significantly higher proficiency and confidence after the skills training session compared to baseline and post-lecture levels. The integrated training model proposed in this study led to significant improvements in theoretical knowledge, technical skills, and confidence. Furthermore, after the training, participants demonstrated proficiency in the guideline-recommended scalpel cricothyrotomy technique, achieving desirable outcomes within a short training period. This study has several limitations: (1) We did not include a control group that received only a single teaching modality, such as a lecture or skills practice alone. This means our study cannot directly quantify the incremental effectiveness of the combined teaching approaches we tested—for example, we cannot definitively confirm whether pairing lectures with hands-on skills practice yields better learning outcomes than using either modality in isolation. As a result, the conclusions about our intervention’s superiority over single-modality training remain tentative, requiring further research with a control group to validate. (2) The long-term retention of skills and knowledge was not assessed. Future studies should incorporate follow-up assessments at 3–6 months to evaluate skill decay and determine the optimal interval for refresher training. Besides, simultaneously analyze the retention differences among trainees with different years of work experience (e.g., 10 years) is needed to provide a basis for personalized training programs. (3) To address the performance anxiety and stress experienced by medical personnel in real-world clinical scenarios, future training should incorporate situational simulations—such as voice and environmental setting simulations. Conclusion In conclusion, the integrated training model combining theoretical instruction, skills training, and assessment is an effective and feasible approach for teaching scalpel cricothyrotomy to medical personnel. This modality enables trainees to rapidly improve their theoretical knowledge, technical proficiency, skill fluency, and confidence. Declarations Funding : Key Laboratory of Traditional Chinese Medicine Syndromes, The First Affiliated Hospital of Guangzhou University of Chinese Medicine (Authorized by SATCM), Guangzhou 510405, China Competing interests : The authors declare no competing interests. Contribution s : Yuhao ZHANG Writing (original draft), Yangkun Li and Jiacheng Fu Visualization and Data curation. Wuhua Ma and Yong Wang: Methodology, Conceptualization, Writing (review & editing), Supervision, Conceptualization. Data availability: The data are available from the corresponding author upon reasonable request. References Pujari V. Front of Neck Access Procedures. In: Ubaradka RS, Gupta N, Bidkar PU, Tripathy DK, Gupta A, editors. The Airway Manual: Practical Approach to Airway Management. Singapore: Springer Nature; 2023. pp. 421–449. doi:10.1007/978-981-19-4747-6_25 Rosenstock CV, Nørskov AK, Wetterslev J, Lundstrøm LH, the Danish Anaesthesia Database. Emergency surgical airway management in Denmark: a cohort study of 452 461 patients registered in the Danish Anaesthesia Database. BJA Br J Anaesth. 2016;117: i75–i82. doi:10.1093/bja/aew190 Jr SLB. Adjuncts for Care of the Surgical Patient, An Issue of Atlas of the Oral & Maxillofacial Surgery Clinics 23-2: Adjuncts for Care of the Surgical Patient, An Issue of Atlas of the Oral & Maxillofacial Surgery Clinics 23-2. Elsevier Health Sciences; 2016. Lavery GG, McCloskey BV. The difficult airway in adult critical care. Crit Care Med. 2008;36: 2163. doi:10.1097/CCM.0b013e31817d7ae1 Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†. BJA Br J Anaesth. 2015;115: 827–848. doi:10.1093/bja/aev371 Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, et al. Surgical intervention during a Can’t intubate Can’t Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)? †. BJA Br J Anaesth. 2016;117: 426–428. doi:10.1093/bja/aew221 Van Zundert AA, Endlich Y, Beckmann LA, Bradley WP, Chapman GA, Heard AM, et al. 2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group. Anaesth Intensive Care. 2021;49: 257–267. doi:10.1177/0310057X20984784 Saul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med. 2023;13: 1327. doi:10.3390/jpm13091327 Makowski AL. A Survey of Graduating Emergency Medicine Residents’ Experience with Cricothyrotomy. West J Emerg Med. 2013;14: 654–661. doi:10.5811/westjem.2013.7.18183 Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy – a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21: 43. doi:10.1186/1757-7241-21-43 Cook TM, Woodall N, Frerk C, on behalf of the Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia†. BJA Br J Anaesth. 2011;106: 617–631. doi:10.1093/bja/aer058 Chang RS, Hamilton RJ, Carter WA. Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training. Acad Emerg Med. 1998;5: 247–251. doi:10.1111/j.1553-2712.1998.tb02621.x King DR, Ogilvie MP, Velmahos G, Alam HB, deMoya MA, Wilcox SR, et al. Emergent cricothyroidotomies for trauma: training considerations. Am J Emerg Med. 2012;30: 1429–1432. doi:10.1016/j.ajem.2011.10.026 Wong DT, Chung FF. What Is the Minimum Training Required for Successful Cricothyroidotomy? 2003;98. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7752213","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":586477280,"identity":"96b6a481-58b3-419e-9265-51b5d1d483b5","order_by":0,"name":"Yuhao Zhang","email":"","orcid":"","institution":"The First Clinical Medical College of Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuhao","middleName":"","lastName":"Zhang","suffix":""},{"id":586477282,"identity":"332e46d7-121d-4fb2-8f1f-bc0e867028e2","order_by":1,"name":"Yangkun Li","email":"","orcid":"","institution":"The First Clinical Medical College of Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yangkun","middleName":"","lastName":"Li","suffix":""},{"id":586477283,"identity":"71c3e839-4c1d-4c69-8a5c-29a213d751ce","order_by":2,"name":"Jiacheng Fu","email":"","orcid":"","institution":"The First Clinical Medical College of Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jiacheng","middleName":"","lastName":"Fu","suffix":""},{"id":586477284,"identity":"e597b1f9-330c-46d7-84fc-161beb457250","order_by":3,"name":"Wuhua Ma","email":"","orcid":"","institution":"The First Affiliated Hospital of Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wuhua","middleName":"","lastName":"Ma","suffix":""},{"id":586477285,"identity":"b3b642b9-8ffc-4d84-b57a-18a62b681278","order_by":4,"name":"Yong Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDADfhDxgIHBgHgtkg0MjA0JJGkxOECsFoPjvYdf89Tcsdt8vMf8QUKFjTED++GjG/BqOXMuzZrn2LPkbWfOGDYknEkzY+BJS7uBV8uNHDPjHLbDyWY3cgwbEtsO2zBI8JgRoeXf4WTjGSRoMX6c23bYzkACosWMoBbJM2fMmP/2HU6QOHOscAbQL8ZshPzCd7zH+OOMb4ft+dubN3z4UGFj2M9++BheLQoHGNgkgHRiA0yEDZ9yEJBvYGD+AKTtCSkcBaNgFIyCEQwAwPdRb8P4ozoAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Guangzhou University of Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-09-30 13:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7752213/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7752213/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102230768,"identity":"552af887-b281-4754-879b-9250f86a2e0b","added_by":"auto","created_at":"2026-02-09 15:27:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":424956,"visible":true,"origin":"","legend":"\u003cp\u003eThe practice protocol of cricothyrotomy training.\u003c/p\u003e\n\u003cp\u003eA, Position the pig model and prepare the surgical area.\u003c/p\u003e\n\u003cp\u003eB, First make a transverse incision, then convert it to a longitudinal position.\u003c/p\u003e\n\u003cp\u003eC, Insert the guide wire through the incision.\u003c/p\u003e\n\u003cp\u003eD, Introduce the dilator along the guide wire.\u003c/p\u003e\n\u003cp\u003eE, Place the tracheostomy tube into the airway.\u003c/p\u003e\n\u003cp\u003e(Guided by 2022 version of ASA difficult airway management practice guidelines.)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7752213/v1/5f4a01dbf858de46b009eb5d.png"},{"id":107529740,"identity":"46e0b6a6-3abd-4b74-ac0e-a63552226fe8","added_by":"auto","created_at":"2026-04-22 10:12:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":786824,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7752213/v1/77736d72-ffe6-4d41-861d-209ea9cba0fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application Effect of a Porcine Trachea Model in Cricothyrotomy Teaching and Training","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAirway management is a fundamental clinical skill that all medical personnel must master. Cricothyrotomy, a critical procedure involving either puncture or incision of the cricothyroid membrane, serves as the final line of defense in securing a patient\u0026apos;s airway. It is an essential life-saving intervention used to resolve upper airway obstruction caused by factors such as tracheal blockage or bronchospasm, thereby maintaining airway patency and improving patient oxygenation. It is a vital and effective emergency procedure for managing conditions like asphyxia and laryngeal edema. In emergent scenarios involving upper airway obstruction or severe maxillofacial trauma, where tracheal intubation is either impossible or has failed, immediate cricothyrotomy should be performed.\u003c/p\u003e\n\u003cp\u003eWhile cricothyroid puncture can be performed, its efficacy in providing adequate ventilation is not guaranteed due to the limited diameter of the needle. In contrast, cricothyrotomy is a rapid and relatively simple procedure that can provide effective oxygenation and ventilation, making it the indispensable rescue skill in a \u0026quot;Can\u0026apos;t Intubate, Can\u0026apos;t Oxygenate\u0026quot; (CICO) crisis.\u003c/p\u003e\n\u003cp\u003eDrawing upon existing literature and prior training experience, this study implemented a training program for cricothyrotomy using a porcine trachea model. The program integrated theoretical instruction, hands-on skills training, and comprehensive assessment. The objective is to evaluate the effectiveness of this approach and to propose a feasible, time-efficient, and highly effective training modality for medical personnel to master this critical skill, and ultimately ensure the safety of patients\u0026apos; lives.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eSource of Biological Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe porcine tracheae used in this training model were procured as by-products from a local abattoir (market) and were purchased commercially. No animals were sacrificed specifically for the purpose of this study. The use of such tissue is therefore exempt from approval by an institutional animal ethics committee, as it utilizes tissue that would otherwise be discarded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 65 trainees participating in an airway management training program at The First Affiliated Hospital of Guangzhou University of Chinese Medicine between January and July 2025 were enrolled in this study. The cohort comprised 42 resident physicians and 23 attending physicians.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) No prior formal training in cricothyrotomy.\u003c/p\u003e\n\u003cp\u003e(2) Voluntary participation in the training program.\u003c/p\u003e\n\u003cp\u003eExclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) Inability to attend the entire training program, including all skills assessments.\u003c/p\u003e\n\u003cp\u003e(2) Failure to complete all required questionnaires, including the theoretical knowledge tests and self-evaluations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design and Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe training program consisted of two parts: theoretical instruction and skills training. All participants underwent a theoretical knowledge assessment and a self-evaluation questionnaire at three time points: 5 minutes before the training, 5 minutes after the theoretical instruction, and 5 minutes after the skills training. Skills assessments were conducted 10 minutes after the completion of both the theoretical instruction and the skills training sessions, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Instruction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe theoretical instruction covered relevant neck anatomy, including the cricothyroid membrane, thyroid cartilage, and cricoid cartilage, as well as knowledge related to the scalpel cricothyrotomy technique [1]. The anatomy lecture focused specifically on adjacent bony structures, muscle tissues, and the surface landmarking of the cricothyroid membrane. The duration of the theoretical instruction was 30 minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Knowledge Assessment and Self-Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTheoretical knowledge was assessed using an electronic questionnaire. Self-evaluation included scores for operational proficiency and confidence. Proficiency was rated on a Numeric Rating Scale (NRS) [2], where participants selected a number from 0 (not proficient) to 10 (very proficient), with 1-3 representing basic proficiency and 4-6 representing moderate proficiency. Confidence was rated on a 5-point Likert scale [3], where 1 = very unconfident, 3 = uncertain, and 5 = very confident.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSkills Training and Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the skills training session, an instructor demonstrated the cricothyrotomy procedure on a porcine trachea model (a complete porcine larynx including the epiglottis, glottis, thyroid cartilage, cricothyroid membrane, cricoid cartilage, and trachea). The instructor also addressed questions that arose during the theoretical session. The skills training session lasted for 45 minutes. For hands-on practice, participants were divided into small groups, with no more than five trainees per group. Details of the practice are provided in Fig1. Cricothyrotomy skills were assessed after the theoretical instruction and again after the skills training. During the assessment, an instructor evaluated and timed each trainee\u0026apos;s performance using a standardized scoring checklist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following data were collected: (1) General demographic information of the trainees, including academic qualifications and years of work experience; (2) Theoretical knowledge scores of trainees before training, after theoretical instruction, and after skills training; (3) Success rate and time taken for performing cricothyrotomy on the porcine model; (4) Trainee confidence scores before training, after theoretical instruction, and after skills training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS version 25.0. Normally distributed continuous data were expressed as mean \u0026plusmn; standard deviation (SD) and compared using the t-test. Repeated measures data were analyzed using one-way analysis of variance (ANOVA). Non-normally distributed continuous data were expressed as median (interquartile range, Q1-Q3) and compared using the Mann-Whitney U test. Categorical data were presented as counts (percentages) and compared using the Chi-square (\u0026chi;\u0026sup2;) test. A P-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project is derived from the Traditional Chinese Medicine (TCM) Continuing Education Program (GZZYJJTJ1917029), which was reviewed, discussed and approved for implementation by the Expert Committee of the State Administration of Traditional Chinese Medicine (SATCM). The Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine waived ethical review for this project, as it had already passed SATCM\u0026rsquo;s expert review.\u003c/p\u003e\n\u003cp\u003ePrior to the project, participants received training and were informed of project details. The study was conducted in line with the Declaration of Helsinki, with informed consent obtained from all participants. Additionally, the data collected was objective and authentic, with no privacy concerns involved.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 62 trainees successfully completed all theoretical, self-evaluation, and skills assessments. The cohort consisted of 38 females (61.29%) and 24 males (38.71%). Regarding academic qualifications, 11 (17.74%) held a bachelor\u0026apos;s degree, 44 (70.97%) a master\u0026apos;s degree, and 7 (11.29%) a doctoral degree. In terms of professional experience, 25 trainees (40.32%) had less than 5 years of experience, 32 (51.61%) had 5 to 10 years, and 5 (8.06%) had over 10 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Knowledge Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean theoretical knowledge scores were 71.85 \u0026plusmn; 11.50 pre-training, 92.58 \u0026plusmn; 5.78 after theoretical instruction, and 95.00 \u0026plusmn; 3.37 after skills training. Compared to the pre-training scores, a significant improvement was observed after both theoretical instruction (P \u0026lt; 0.001) and skills training (P \u0026lt; 0.001). Furthermore, scores after skills training were significantly higher than those after theoretical instruction alone (P \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSkills Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success rate for performing scalpel cricothyrotomy on the porcine model increased from 75.8% (47/62) after theoretical instruction to 95.2% (59/62) after skills training. The mean skills assessment score significantly increased from 70.74 \u0026plusmn; 1.74 after theoretical instruction to 95.08 \u0026plusmn; 0.49 after skills training (P \u0026lt; 0.001). Concurrently, the mean time required to complete the procedure was significantly reduced from 46.72 \u0026plusmn; 1.97 seconds to 22.20 \u0026plusmn; 0.67 seconds (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean self-reported confidence scores were 1.58 \u0026plusmn; 1.02 pre-training, 3.23 \u0026plusmn; 1.06 after theoretical instruction, and 4.29 \u0026plusmn; 0.93 after skills training. Compared to baseline, trainee confidence increased significantly after both theoretical instruction (P \u0026lt; 0.001) and skills training (P \u0026lt; 0.001). Confidence levels were also significantly higher after skills training compared to after theoretical instruction alone (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe self-rated proficiency score for performing scalpel cricothyrotomy on the porcine model was significantly higher after skills training (8.28 \u0026plusmn; 1.35) compared to after theoretical instruction (5.74 \u0026plusmn; 0.88) (P \u0026lt; 0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCricothyroidotomy (puncture or incision) and tracheostomy are essential components of front-of-neck airway (FONA) rescue[1]. Although infrequently performed in practice, these procedures play an irreplaceable role in rescuing patients with upper airway obstruction or an unanticipated difficult airway. Failure to establish a timely and effective surgical airway can lead to irreversible brain injury or death[2]. Tracheostomy is a well-known method for establishing an airway[3], and historically, its mastery was required for all surgeons. However, with technological advancements and increasing sub-specialization, this requirement has diminished. Inexperienced junior surgeons may find it more time-consuming compared to cricothyrotomy[3,4]. Consequently, an increasing number of airway management guidelines recommend that anesthesiologists opt for cricothyrotomy in \u0026quot;Can\u0026apos;t Intubate, Can\u0026apos;t Oxygenate\u0026quot; (CICO) scenarios [5,6].\u003c/p\u003e\n\u003cp\u003eThe incidence of CICO emergencies has decreased with the widespread adoption of advanced airway devices such as video laryngoscopes, laryngeal masks, and flexible endoscopes[7,8]. As a result, many medical professionals lack experience with cricothyrotomy[9]. Emergency cricothyroid puncture, due to the small cannula diameter and difficulty in securing the device, often fails to provide sustained, effective ventilation. In contrast, cricothyrotomy is a rapid and relatively simple procedure that provides effective oxygenation and ventilation, positioning it as the definitive solution in the emergency airway algorithm[10]. However, studies have revealed a lack of experience in performing surgical airways among anesthesiologists and a low success rate for the procedure[5,11]. Therefore, enhancing the training of medical personnel in cricothyrotomy is of paramount importance.\u003c/p\u003e\n\u003cp\u003eWhile clinical practice is an effective way to improve skills, the low incidence of cricothyrotomy and the need for it to be performed by the most experienced physician preclude its use as a training opportunity[12\u0026ndash;14]. In this study, based on existing literature and prior experience, we utilized a porcine trachea model that includes the thyroid cartilage, cricoid cartilage, and cricothyroid membrane. This model provides realistic anatomical landmarks, closely simulating the actual procedure and facilitating rapid skill acquisition. We adopted a multimodal teaching approach that integrated \u0026quot;theoretical instruction, skill demonstration, small-group practice, and assessment.\u0026quot; This structure allowed trainees to build upon a theoretical foundation with hands-on training. The small-group practice sessions were designed to enhance trainee engagement and learning efficiency, enabling instructors to monitor individual progress and provide immediate corrective feedback. The effectiveness of this training model was evaluated across three dimensions: theoretical knowledge, technical skill, and self-assessment. Our results demonstrate that this combined approach led to a significant improvement in theoretical knowledge, proving superior to theoretical instruction alone.\u003c/p\u003e\n\u003cp\u003eRegarding self-evaluation, trainees reported significantly higher proficiency and confidence after the skills training session compared to baseline and post-lecture levels. The integrated training model proposed in this study led to significant improvements in theoretical knowledge, technical skills, and confidence. Furthermore, after the training, participants demonstrated proficiency in the guideline-recommended scalpel cricothyrotomy technique, achieving desirable outcomes within a short training period.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations:\u003c/p\u003e\n\u003cp\u003e(1) We did not include a control group that received only a single teaching modality, such as a lecture or skills practice alone. This means our study cannot directly quantify the incremental effectiveness of the combined teaching approaches we tested\u0026mdash;for example, we cannot definitively confirm whether pairing lectures with hands-on skills practice yields better learning outcomes than using either modality in isolation. As a result, the conclusions about our intervention\u0026rsquo;s superiority over single-modality training remain tentative, requiring further research with a control group to validate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(2) The long-term retention of skills and knowledge was not assessed. Future studies should incorporate follow-up assessments at 3\u0026ndash;6 months to evaluate skill decay and determine the optimal interval for refresher training. Besides, simultaneously analyze the retention differences among trainees with different years of work experience (e.g., \u0026lt;5 years vs. \u0026gt;10 years) is needed to provide a basis for personalized training programs.\u003cbr\u003e\u0026nbsp;(3) To address the performance anxiety and stress experienced by medical personnel in real-world clinical scenarios, future training should incorporate situational simulations\u0026mdash;such as voice and environmental setting simulations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the integrated training model combining theoretical instruction, skills training, and assessment is an effective and feasible approach for teaching scalpel cricothyrotomy to medical personnel. This modality enables trainees to rapidly improve their theoretical knowledge, technical proficiency, skill fluency, and confidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e: Key Laboratory of Traditional Chinese Medicine Syndromes, The First Affiliated Hospital of Guangzhou University of Chinese Medicine (Authorized by SATCM), Guangzhou 510405, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContribution\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003es\u003c/em\u003e\u003c/strong\u003e: Yuhao ZHANG Writing (original draft), Yangkun Li and Jiacheng Fu Visualization and Data curation. Wuhua Ma and Yong Wang: Methodology, Conceptualization, Writing (review \u0026amp; editing), Supervision, Conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData availability:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe data are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePujari V. Front of Neck Access Procedures. In: Ubaradka RS, Gupta N, Bidkar PU, Tripathy DK, Gupta A, editors. The Airway Manual: Practical Approach to Airway Management. Singapore: Springer Nature; 2023. pp. 421\u0026ndash;449. doi:10.1007/978-981-19-4747-6_25\u003c/li\u003e\n\u003cli\u003eRosenstock CV, N\u0026oslash;rskov AK, Wetterslev J, Lundstr\u0026oslash;m LH, the Danish Anaesthesia Database. Emergency surgical airway management in Denmark: a cohort study of 452 461 patients registered in the Danish Anaesthesia Database. BJA Br J Anaesth. 2016;117: i75\u0026ndash;i82. doi:10.1093/bja/aew190\u003c/li\u003e\n\u003cli\u003eJr SLB. Adjuncts for Care of the Surgical Patient, An Issue of Atlas of the Oral \u0026amp; Maxillofacial Surgery Clinics 23-2: Adjuncts for Care of the Surgical Patient, An Issue of Atlas of the Oral \u0026amp; Maxillofacial Surgery Clinics 23-2. Elsevier Health Sciences; 2016. \u003c/li\u003e\n\u003cli\u003eLavery GG, McCloskey BV. The difficult airway in adult critical care. Crit Care Med. 2008;36: 2163. doi:10.1097/CCM.0b013e31817d7ae1\u003c/li\u003e\n\u003cli\u003eFrerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults\u0026dagger;. BJA Br J Anaesth. 2015;115: 827\u0026ndash;848. doi:10.1093/bja/aev371\u003c/li\u003e\n\u003cli\u003ePracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, et al. Surgical intervention during a Can\u0026rsquo;t intubate Can\u0026rsquo;t Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)? \u0026dagger;. BJA Br J Anaesth. 2016;117: 426\u0026ndash;428. doi:10.1093/bja/aew221\u003c/li\u003e\n\u003cli\u003eVan Zundert AA, Endlich Y, Beckmann LA, Bradley WP, Chapman GA, Heard AM, et al. 2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group. Anaesth Intensive Care. 2021;49: 257\u0026ndash;267. doi:10.1177/0310057X20984784\u003c/li\u003e\n\u003cli\u003eSaul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med. 2023;13: 1327. doi:10.3390/jpm13091327\u003c/li\u003e\n\u003cli\u003eMakowski AL. A Survey of Graduating Emergency Medicine Residents\u0026rsquo; Experience with Cricothyrotomy. West J Emerg Med. 2013;14: 654\u0026ndash;661. doi:10.5811/westjem.2013.7.18183\u003c/li\u003e\n\u003cli\u003eLangvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy \u0026ndash; a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21: 43. doi:10.1186/1757-7241-21-43\u003c/li\u003e\n\u003cli\u003eCook TM, Woodall N, Frerk C, on behalf of the Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia\u0026dagger;. BJA Br J Anaesth. 2011;106: 617\u0026ndash;631. doi:10.1093/bja/aer058\u003c/li\u003e\n\u003cli\u003eChang RS, Hamilton RJ, Carter WA. Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training. Acad Emerg Med. 1998;5: 247\u0026ndash;251. doi:10.1111/j.1553-2712.1998.tb02621.x\u003c/li\u003e\n\u003cli\u003eKing DR, Ogilvie MP, Velmahos G, Alam HB, deMoya MA, Wilcox SR, et al. Emergent cricothyroidotomies for trauma: training considerations. Am J Emerg Med. 2012;30: 1429\u0026ndash;1432. doi:10.1016/j.ajem.2011.10.026\u003c/li\u003e\n\u003cli\u003eWong DT, Chung FF. What Is the Minimum Training Required for Successful Cricothyroidotomy? 2003;98. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cricothyrotomy, Porcine trachea, Training, Postgraduate medical education","lastPublishedDoi":"10.21203/rs.3.rs-7752213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7752213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To investigate the application of a porcine trachea model for teaching and training in cricothyrotomy and to provide a novel method for clinical teaching and training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Trainees undergoing airway management training at The First Affiliated Hospital of Guangzhou University of Chinese Medicine from January to July 2025 were enrolled. A training model combining theoretical instruction, skills training, and assessment was adopted, utilizing a porcine trachea model for cricothyrotomy training. Theoretical knowledge scores and self-evaluations were recorded before training, after theoretical instruction, and after skills training. Skill assessment scores and operation times were recorded after both the theoretical and skills training sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 62 trainees completed the theoretical, self-evaluation, and skills assessments. Compared to pre-training levels, theoretical knowledge scores were significantly higher after both theoretical instruction (P \u0026lt; 0.001) and skills training (P \u0026lt; 0.001). Furthermore, theoretical scores after skills training were significantly higher than those after theoretical instruction alone (P\u0026lt;0.01). Compared to the post-theoretical instruction assessment, skills assessment scores were significantly higher (P\u0026lt;0.001) and operation times were significantly shorter (P \u0026lt;0.001) after skills training. Trainee confidence was significantly improved after both theoretical instruction (P\u0026lt;0.001) and skills training (P\u0026lt;0.001) compared to baseline. Confidence was also significantly higher after skills training compared to after theoretical instruction alone (P\u0026lt;0.001). The proficiency score for performing scalpel cricothyrotomy on the porcine trachea model was significantly higher after skills training than after theoretical instruction (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The training model that combines theoretical instruction, skills training, and assessment is an effective and feasible method for postgraduate medical personnel to learn cricothyrotomy skills. This model enables trainees to enhance their theoretical knowledge, practical skills, and confidence within a short period.\u003c/p\u003e","manuscriptTitle":"Application Effect of a Porcine Trachea Model in Cricothyrotomy Teaching and Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 15:27:13","doi":"10.21203/rs.3.rs-7752213/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03ba9cfa-77ee-4a9a-a4e0-384564dd29be","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62399634,"name":"Health sciences/Health care"},{"id":62399635,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-22T10:11:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 15:27:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7752213","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7752213","identity":"rs-7752213","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}